CHIP Complaints and Appeals

What can I do if DentaQuest denies or limits a service for my child that the dentist has asked for? Can I just ask for an appeal or does it have to be in writing?

You can ask for an appeal in writing, or you can call and ask DentaQuest for an appeal. We will send you a one-page appeal form that you, your child's dentist, or someone else representing you can fill out and return to us. Our address to mail your appeal to is:

DentaQuest-TX
Attn: Appeal Department
Stratum Executive Center11044 Research Blvd
Building D, Suite D-400
Austin, TX 78759 You may use this form if you would like to write to us: TX CHIP Appeal Form

Or call us toll-free at: 1-800-508-6775

How will I find out if services are denied?

We will send you and your dentist a letter. You can also call our Member Call Center and we can tell you the status of your authorization. Call us at 1-800-508-6775.

What are the time frames for the appeal process?

Once we get your appeal, we will process and respond within 30 calendar days. You may ask for an extension, or we may tell you that we need more time in order to get more information. We will only ask for an extension if the delay will help you.

When can I ask for an appeal?

You have the right to ask for an appeal if you are not happy with the decision to your complaint. You can also ask for an appeal due to an adverse determination. This is a denial where DentaQuest decides that the service is not medically necessary. However, you cannot appeal a decision related to:

• Annual maximum benefits.
• Member eligibility.
   

Can I just ask for an appeal or does it have to be in writing?

You can ask for an appeal in writing, or you can call and ask DentaQuest for an appeal. We will send you a one-page appeal form that you, your child's dentist, or someone else representing you can fill out and return to us. Our address to mail your appeal to is:

DentaQuest-TX
Attn: Appeal Department
Stratum Executive Center
11044 Research Blvd
Building D, Suite D-400
Austin, TX 78759

Or call us toll-free: 1-800-508-6775

You may call our Member Call Center to ask for an appeal. Within five (5) business days after you call, we will send you an appeal form. We must get your completed, signed appeal form to confirm your appeal request. (If your appeal request is related to a dental emergency, we do not need a completed, signed form to process the appeal). We will send you a letter to let you know we got your appeal. We will make a decision no later than the 30th calendar day after the date we get the appeal.

Can someone from DentaQuest help me file an appeal?

A DentaQuest Member Advocate can help you file an appeal. Please call our Member Call Center for help. The toll-free number is 1-800-508-6775. Tell us that you want to file an appeal and one of our Member Advocates will help you file the appeal.

What else can I do if I'm still not happy?

You or someone you name to act for you may file a request for external review within four months of receiving our appeal resolution letter. To ask for an IRO, you must fill out the “HHS Administered Federal External Review Request Form” that will be included with the appeal resolution letter. If you want to send more information to include in the review, you can send it with your request. You don’t have to pay for this review or any filing fees. If you would like to have another person make an external review request on your behalf, both you and your authorized representative will need to complete and sign the Appointment of Representative Form (under the “Forms” heading). Our address to mail your form is:

MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
Fax: 1-888-866-6190

Online: Request a review online at externalappeal.com. If you believe your case is urgent and should be expedited, you can select “expedited” if submitting the review request online, or by emailing FERP@maximus.com, or calling Federal External Review Process at 1-888-866-6205, ext. 3326. MAXIMUS Federal Services will provide notice of the final external review decision as expeditiously as your medical conditions or circumstances require, but in no event more than 72 hours after they receive a request for an expedited external review. When MAXIMUS Federal Services receives your request, they will notify us, and we’ll send them all the case information for review. If you send them any more information they’ll share it with us. We may change our decision. If not, the IRO will continue the review. You’ll receive a letter with their decision for a standard request no later than 45 days after they receive the request for the external review. If MAXIMUS Federal Services decides to overturn our decision, we will provide coverage or payment for your health care items or services.

If you have questions or concerns about your external review, call 1-888-866-6205.

What is an Expedited Appeal?

Ask for an Expedited Appeal when you don't have time for a standard appeal - when your child's life or health is in danger. When you ask for an expedited appeal, DentaQuest has to make a decision quickly based on the condition of your child's health.

How do I ask for an Expedited Appeal?

You can call us to file an expedited appeal. We do not need your appeal in writing for an expedited appeal. If you need help to file an expedited appeal, call our member call center for help. The toll-free number is 1-800-508-6775. Tell us that you want to file an expedited appeal.

How long does an expedited appeal take?

We will make a decision within three (3) business days after we get your expedited appeal.

What happens if DentaQuest says it won't do an expedited appeal?

If DentaQuest does not think your appeal is life-threatening, we will let you know the same day that the decision is made. DentaQuest will make this decision within three (3) business days. Your appeal will still be worked on, but the decision may take up to 30 days.

Who can help me file an Expedited Appeal?

If you or your representative need help in filing an expedited appeal, call our member call center and one of our Member Advocates can help. The toll-free number is 1-800-508-6775. Tell us that you want to file an expedited appeal.